Pulmonary Embolism.

Question 1

Essentials of Diagnosis:

-Predisposition to venous thrombosis, especially in the lower extremities.

-Acute onset of dyspnea, pleuritic chest pain, tachypnea, and tachycardia.

-Elevated rapid D-dimer, characteristic defects on ventilation-perfusion lung scan, helical CT scan, or pulmonary angiogram.

Answer 1

Pulmonary Embolism

Question 2

General Considerations

Occur when an embolus lodges within the pulmonary circulation.

Sources of emboli:
Emboli are most commonly thrombi.
- Air (secondary to neurosurgery)
- Amniotic fluid (during childbirth)
- Fat (long bone fractures)
- Foreign bodies (IV drug use, retained catheter fragment)
- Parasite eggs (schistosomiasis)
- Septic emboli (infectious endocarditis)
- Tumors

Answer 2

Pulmonary Embolism

Question 3

• Clots that form are most commonly from the femoral or pelvic venous beds.

Clots confined to the lower leg and upper extremity rarely embolize into the pulmonary circulation.

Dx will develop within 50-60% of patients with proximal deep vein thrombosis.

50-70% of patients with symptomatic Dx will have lower extremity DVT.

Answer 3

Pulmonary Embolism

Question 4

Venous stasis
Injury to the vessel wall
Hypercoagulability

• OCP, hormone replacement Inherited gene defects contribute to hypercoagulability

Answer 4

(Virchow’s Triad): Pulmonary Embolism

Question 5

Physical Findings:

Onset often is abrupt, and one or more of the DVT risk factors is almost always present.

Dyspnea, cough, anxiety, and chest pain occur in varying combinations.

Hemoptysis, tachycardia, and tachypnea are common.

Low grade fever, hypotension, cyanosis, DVT signs, and pleural friction rub may be present.

Answer 5

Pulmonary Embolism

Question 6

Operational environment requires the IDC to rely on history and physical exam for recognition and early treatment

• Reference standard for diagnosis is pulmonary angiography.

Clinical prediction tools (Wells criteria or PERC; scores > 5 Dx is likely)

• Although not specific for Dx, the ECG may show ST and T wave abnormalities.

Answer 6

Pulmonary Embolism

Question 7

Imaging Findings:
1. The reference standard for Dx diagnosis is pulmonary angiography.
2. CXR may show atelectasis, infiltrates, and effusions.
3. ST Elevation

Answer 7

Pulmonary Embolism

Question 8

Treatment:

Oxygen
2 – 15 LPM based on oxygen saturation and respiratory effort.
* Delivered through nasal cannula, simple mask, non-rebreather mask, or advanced airway.

Enoxaparin (Lovenox) LMWH (low molecular weight heparin) as effective as Heparin (unfractionated heparin).
Dose: Lovenox 1 mg/kg subcutaneously q 12 hours.

Streptokinase, urokinase, and recombinant tissue plasminogen activator “clot busters” lysis

Answer 8

Pulmonary Embolism

Question 9

Disposition:
Patients will need ongoing anticoagulation and supportive care.
The IDC will not manage the care of this patient. MEDEVAC as soon as possible.

Complications
Missed diagnosis is common.
In the majority of deaths, is not recognized ante mortem or death occurs before specific treatment can be initiated.

Patients whom anticoagulation or thrombolytic therapy is contraindicated may require surgical intervention to remove the clot.

Answer 9

Pulmonary Embolism